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HomeMy WebLinkAboutTremont St. #140 - 3/15/2005MANSFIELD BOARD OF HEALTH APPLICATION FOR PERMIT TO DRILL WELL Name Qr � J_eeu e d' Z 1 et7eSGLi l Address: d yd %Tt'evn S i Telephone Location: Redg - .t-etT"" 5 s be- Registered Well Driller:'r -e �u,erQ MA Lic # Address: /� �,Q,,,z_ fhrL ?rIG SSQT- n2A sa t; c�c c soya9y.�/�� TYPE OF WELL: Dom�estic Potable (for household use) A 1-- omestic Auxiliary (for watering, pools, etc.) _ Industrial/Commercial Potable (for human consumption, including food processing) _ Industrial/Commercial Auxiliary (for manufacturing, etc.) Agricultural (for irrigation of land in the business of agriculture) Fee: ---6omestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural Date: 2, --t ��- O S� Applicant Signature: PERMIT TO DRILL WELL The above application has been appro-v following use at 'T 1, —a and permission is granted to drill a well for the _ Domestic Potable (for household use) t Domestic Auxiliary (for watering, pools, etc.) Industrial/Commercial Potable (for human consumption, including food processing) Industrial/Commercial Auxiliary (for manufacturing, etc.) _ Agricultural (for irrigation of land in the business, of agriculture) Date: Approved by: i or the Board of Health NOTE. Electrical permit required; underground cable trench must be inspected. Upon Installation of well, call Department of Public Works office at 261- 733 0 to be added to well list; Massachusetts Department of Environmental Management Office of Water Resources at. TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS (OPTIONAL) LATITUDE _° LONGITUDE _ DATUM Address at Well Location: i� <T 1 j ,' yi.✓"r Property Owner/Client. - o - Subdivision Name: Mailing Address:= " '` ` City/Town: _. r-r<� r� i3 City/Town: Assessors Map Assessors Lot #: NOTE: Assessors Map and Lot If mandatory if no street address available Board of Health permit obtained: Yes ❑ Not Required ❑ Permit Number P�Q2Qelssued 2. WORK PERFORMED 3. PROPOSED USE 14. DRILLIN ❑ New Well ❑ Abandon ❑ Domestic ❑' Irrigation ❑Cable ET ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑" Air HAr /(7 Direct Pdsf❑ Re lace ❑ Other ❑ Industrial ❑ Other ❑ Mud jtJAllbe S. WELL LOG Water Bearinga Unconsolidated Consolidated 16. SITE SKET (Use permanent tagdma ces) ro .. — d d Other Rock T e YP anP From (ft) To (ft) Zone 5 ur m Material Description 3 " 7.WELL CONSTRUCTION 8.'CASING Total Depth Drilled ! ' i:' From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type / ff Date Complete ,� ��� 9.SCREEN From (ft) To (it) Slot Size Screen Type and Material Screen Diameter 10. FILTER PACK / GROUT! ABANDONMENT MATERIAL 11.'ADDITIONAL WELL INFORMATION Developed? ❑"Yes ❑ No From (ft) To (it) Material Description Purpose Fracture Enhancement? ❑ Yes ❑` No Method Disinfected? © Yes ❑ No 12. WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 13. STATIC WATER LEVEL (ALL WELLS).__. Yield Time Pumped Drawdown to Time to Recover Recovery to Depth Below Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) 14. PERMANENT PUMP (IF AVAILABLE) 15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) 16. COMMENTS 17. WELL DRILLER'S STATEMENT :' This well was drilled, altered, and/or abandoned under my supervision, according to applicable rules and regulations, and this report is complete and correct to the best of my knowledge. 1 Driller_ %fT - > J ' 31" �' Supervising Driller Signature: °"��1 Registration Firm:—,'. Date Rig Permit #: NOTE: Well Completion Reports must �e filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY